<link rel="stylesheet" href="Style.css" type="text/css" media="screen, projection" />
<link rel="stylesheet" href="dropdown.css" type="text/css" media="screen, projection" />

<div class = "Form" id = "UserInfoForm">
 <div class = "FormName">
	Client Information
 </div>
 <div class = "DataBlock">
 	
	<div class = "DataBlockSub">
		Client Name:
		<input type = "text" id = "ClientName"  class = "NotEditableTextBox" readonly="readonly"> <br>
		Insurance Company:
		<input type = "text" id = "InsuranceCompany"  class = "NotEditableTextBox" readonly="readonly"><br>
		Policy Number:
		<input type = "text" id = "PolicyNumber"  class = "NotEditableTextBox" readonly="readonly"><br>
	</div>
	
	<div class = "DataBlockSub">
		Effective Date:
		<input type = "date" id = "EffectiveDate"  class = "NotEditableTextBox" readonly="readonly"><br>
		Date of Initial process:
		<input type = "date" id = "InitDate"  class = "NotEditableTextBox" readonly="readonly"><br>
		Date last modified:
		<input type = "date" id = "ModifiedDate"  class = "NotEditableTextBox" readonly="readonly"><br>
	</div>
	
	<div class = "DataBlockSub">
		Policy Cost:
		<input type = "text" id = "PolicyCost"  class = "NotEditableTextBox" readonly="readonly"><br>
		Total Fees & Charges:
		<input type = "text" id = "Fees"  class = "NotEditableTextBox" readonly="readonly"><br>
		Total Policy Cost:
		<input type = "text" id = "TotalPolicyCost"  class = "NotEditableTextBox" readonly="readonly"><br>
	</div>
</div>	
	
	
<div class = "DataBlock">	
	<div class = "DataBlockSub">
		Suffix:
		<select>
			<option>Mr.</option>
			<option>Ms.</option>
		</select><br>
		First Name:
		<input type = "text" id = ""  class = "TextBox"><br>
		Middle Name:
		<input type = "text" id = "" class = "TextBox"><br>
		Last Name:
		<input type = "text" id = "" class = "TextBox"><br>
	</div>
	
	<div class = "DataBlockSub">
		Gender:
		<select>
			<option>Male</option>
			<option>Female</option>
		</select><br>
	
		Matrial Status:
		<select>
			<option>Married</option>
			<option>Single</option>
		</select><br>
	
		Date of Birth
		<input type = "date" id = "ModifiedDate"  class = "BirthDate" readonly="readonly"><br>
	</div>
	
  </div>
</div>
</div>